Number 412 SL&C 3/23/95 SB 100 DISCRIMINATION UNDER GROUP HEALTH INS.  SENATOR KELLY announced SB 100 to be up for consideration. He said they are working on work draft 9SLS0788/F4 3/22/95 which changes the title and deals with including physician assistant and acupuncturist into the bill. SENATOR MILLER said he understood there were three groups who were interested and all three have merits. He thought it was possible there should be a separate bill for each group. After discussion with committee members SENATOR KELLY said they would begin taking testimony and asked Jack Heesch to address the committee. MR. HEESCH said he would answer questions. JONATHAN SCHAEFFER, Licensed Acupuncturist, said that SB 100 would allow freedom of choice for folks with insurance. This is basically a fundamental right and a principal that this country was based on. Acupuncture is a very safe and effective form of health care for many conditions. In the long run, its use reduces health costs for consumers and insurers. He supported adding physician assistants and acupuncturists to the ranks of the reimbursable health care providers of the state. RACHEL YATES, Alaska Association of Marriage and Family Therapists, said she would like to answer any questions they have about marriage and family therapy. SENATOR KELLY said that he didn't think that what she did, while being very important, was medicine. Personally, he thought the list should just include medical providers. JERRY REINWAND, Blue Cross, said he thought the committee really needed to look at the public policy issues involved in light of the memo from Mr. Koch, Division of Insurance, specifically where he says 090 (d) isn't a mandate, but then says later that it is a mandate. He said he was still unclear about that section. MR. KOCH said perhaps one way to address that question is that if a policy provides coverage for treatment of a headache, then it should extend to anyone on the list who can provide treatment for a headache. If, however, the policy structures itself in a way that says you're addressing a diagnosis as to what's causing the headache, then only those people who can make a diagnosis as to what is causing that headache can be the service providers. He didn't view this as a mandate of coverage. It is intended to be an antidiscrimination provision. It says basically, if a provider can provide a coverage that is covered on a policy and do so within the scope of his license, then you can't discriminate against him. He didn't view this as a mandate. He added this would cause some serious concern for those who don't want to deal with particular professions. MR. REINWAND said that answered his question. SENATOR DUNCAN said he was not sure that was a solution he could support. MR. KOCH explained if the cause of a backache was beyond the scope of an acupuncturists' practice, he would be excluded. The insurer is the one who makes that determination. SENATOR DUNCAN asked if there was nothing to stop insurers from just making a policy call on a corporate level denying acupuncture all together. MR. KOCH replied that if they did that, they would have to be very careful about how they worded the coverages in their policy, because as soon as they provided a coverage that was clearly within the scope of their practice, and allowed another practitioner to perform it, they would be up against discrimination. It's not requiring them to provide the coverage, but it does say that if you provide it, you can't discriminate against those who can provide that service. SENATOR DUNCAN asked if adding acupuncturists to this list would prohibit an insurance contract from specifically excluding acupuncturists. MR. KOCH replied that it would. SENATOR DUNCAN asked who decided what is a valid treatment. MR. KOCH explained that decision goes to the insurer first, and then a complaint could be filed with the Division of Insurance. The Division would review what was within the scope of their practice and, if it's within the scope of their practice, they would go to the insurer and see why they declined to cover it. The courts can also determine what's within the scope of the practice of the acupuncturist. Number 550 SENATOR DUNCAN said he knew of a case where a physician assistant provided some services which were within the scope of a P.A. and provided that service in a physician's office. The physician submitted a claim to the insurance industry and was denied, because it was a physician assistant who did it. He asked if physician assistant were added to the list, could that happen. MR. KOCH said that that could not occur. TAPE 95-14, SIDE B SENATOR SALO asked for his response to Senator Kelly's contention that these should just be medical providers. MR. KOCH said if a group health policy structures itself in a way to provide coverages for things that are not typically within the practice of a physician or extend to other things, then it may be appropriate. The policy states what it's intending to provide. If it says marital counseling and the current list says the only ones who can provide marital counseling are the psychologist or physician, then it is limited to just those. SENATOR DUNCAN said his concern with stating in statute that this is not mandated coverage, that it would give insurers a loophole to say they don't recognize that an acupuncturist provides services. MR. KOCH said he would prefer that language not appear in this section of law and typically the place where mandates of coverage are placed are in chapter 42, the section of law that deals with contract content. Number 552 SENATOR KELLY announced a break from 2:25 - 2:32. MR REINWAND said he still thought the effect of 090 (d) was to mandate coverage. He thought that was a much different policy question than adding people to the list. He thought it would be helpful for the committee to clarify the statute does not mandate coverage. Number 535 LINDA REXWINKEL said her concern was with acupuncture. She said she suffered from a chronic pain syndrome called reflex sympathetic dystrophy which she contracted in 1991. Basically, the sympathetic system in her leg has gone crazy and produces pain on its own initiative in the form of swelling which cut off her circulation, and if left untreated, her leg would gangrene and require amputation. She had no alternative, but to secure medical treatment which has amounted to about $65,000 since 1991. The normal course of treatment for this disorder by the medical profession is an injection of anesthetic which did not work for her at all. Since 1993, she has seen Suzanne Cortright, an acupuncturist here in Juneau. The average cost for the medical treatment that didn't work was about $1,000. Ms. Cortright's treatments are just a fraction of that and the amount of pain relief is substantial. For many people with chronic pain, alternative medicine is about the only course of treatment they have available to them, because the regular medical profession does not fully understand what is happening and can't provide relief. As an employee under the state's plan, her acupuncture was not covered by Aetna Health Plans. She thought she faced unfair discrimination, because she knows people who had acupuncture treatments by physicians who were covered by Aetna. It, therefore, seems to her that we have occupational licensing for various professions, but do not accord them the same kind of treatment as we would an M.D. It seems we allow for coverage of services by a doctor merely because he has an M.D. behind his name, even though he made not have had any specific kind of acupuncture training and merely has someone else administer the needles for him. She said the cost of the treatments between the two would be much less for the acupuncturist. The issue is not only of fair coverage and discrimination, but to provide people with an alternative to traditional medicine when it doesn't work, and to be able to receive reimbursement for it, and also cost containment. SENATOR KELLY said he was in favor of the lower cost, but it seems that they are adding to the list, but no one is saying you only get one of these, so he wondered if there really was any savings in the final analysis. MS. REXWINKEL said she thought there was a cost savings, because people go to whomever their insurance covers. If the alternative is provided, people can go to whomever they want. She did not believe putting acupuncturist in there makes it a mandated service. From when she sold insurance, she recollects that insurance companies have the ability to make discretionary changes in the policies in the coverage they provide. She asked why they wouldn't want it covered, if they are already paying for it under an M.D. and providing alternatives to people is one way to control cost. SENATOR DUNCAN asked why Aetna turned her down. MS. REXWINKEL said "service not covered." She said she didn't realize they were covering acupuncture by a physician in Anchorage until just recently. She has drafted a letter to Aetna and Division of Retirement and Benefits detailing the fact that they are paying for services under a physician in Anchorage, even though they are not paying for her acupuncturist down here. MS. REXWINKEL said her experience with Aetna is that many times it is the initial claims representative, then the claims supervisor, and then it would be a nurse who reviews the file and makes the determination on what is covered. An appeal goes to the Division of Retirement and Benefits who review Aetna's denial and then the courts are beyond that. Number 427 BOB STALNAKER, Director, Division of Retirement and Benefits, said he had a neutral position on SB 100. He said in the case of an M.D. using acupuncture for treatment modalities, they would have to check that out. SENATOR SALO said she didn't think it was unusual to go to a medical doctor, a chiropractor, acupuncturist, or a massage therapist, or whoever to find a solution to your condition. She asked how that was handled under the Aetna system. MR. STALNAKER said he thought that situation would be very rare, and people normally switch providers within the same professional service. SENATOR SALO said she disagreed, that she personally knows people who seek many different kinds of health care, especially when you think of chiropractic services in addition to a medical doctor. MR. STALNAKER noted that the insurer would eventually deny coverage after a point in time, because of improper treatment. SENATOR DUNCAN asked him if he agreed with Mr. Koch's position, that if there is a service specifically covered by Aetna, as in Ms. Rexwinkel's case, and she goes to a physician, they pay the claim. If she goes to an acupuncturist for that condition, Aetna would have to pay the claim also. MR. STALNAKER said that would be correct if acupuncture services were an accepted form of treatment for that ailment. Number 375 SENATOR DUNCAN asked who makes the determination of what's an accepted form of treatment for that condition. MR. STALNAKER said the decision is made by the insurance carrier through generally accepted treatment modalities, the "treatment book." SENATOR DUNCAN asked if the state had any ability to have impact on that. He said he really didn't have too much faith in getting non traditional services covered, because Aetna corporate headquarters could just say they don't accept that as a form of treatment for that particular condition. He didn't see what good it did to have anyone listed, if the state is leaving it up to the insurance industry to make the decision about what are accepted forms of treatment. MR. STALNAKER said there will always be treatments that are not yet medically accepted forms of treatment that over time might become accepted. SENATOR DUNCAN said, in reference to Ms. Rexwinkel's condition, that it was a "fringe condition" and he wanted to see the book that Aetna uses for these determinations. MR. STALNAKER responded that "the book" defines what's an acceptable treatment rather than who is acceptable to do it. If an acupuncturist is licensed to perform that form of treatment, they would be reimbursed. SENATOR DUNCAN said he didn't understand what an acupuncturist's license says. Number 300 SUZANNE CORTRIGHT, Acupuncturist, read the statute definition of an acupuncturist: "A form of healing, developed from traditional Chinese medical concepts, that uses the stimulation of certain points on or near the surface of the body by the insertion of needles to prevent or modify the perception of pain or normalize physiological functions. The practice of acupuncture means the insertion of sterile acupuncture needles and the application of moxibustion to special areas of the human body based upon acupuncture diagnosis. The practice of acupuncture includes adjunctive therapies involving mechanical, thermal, electrical, and electro-magnetic treatment and the recommendation of dietary guidelines and therapeutic exercises." MR. STALNAKER said we pay to have medical experts make those kinds of calls. He felt they would do it without discrimination and with a completely open mind in what is generally accepted in the medical profession. He said acupuncture is allowed as a form of anesthesiology. SENATOR DUNCAN commented that the insurance industry can hire doctors to give opinions like he can hire an attorney to give him an opinion. Number 290 MS. CORTRIGHT presented a list from the World Health Organization of things that are acceptable for treatment by acupuncture. She said insurance coverage for acupuncture increases the efficiency of our health care system. By beginning treatment with the least invasive and least expensive modalities there will be less money spent overall. She said that often her patients have been through months or years of medical treatment that was quite costly and ineffective. Acupuncture often provides relief for them at a small fraction of the cost. If it were covered by insurance, it would provide encouragement for people to seek these less expensive modalities earlier. She said that acupuncture is very effective for addictions. SENATOR TORGERSON asked if her treatment just made people feel better or if it really cured them too. MS. CORTRIGHT said absolutely; the goal is to get people better so that they don't come back. She noted that some insurance companies cover acupuncture (in pilot programs), like Blue Cross and Blue Shield of Washington and Oregon, and they are saving money. Number 211 MS. YATES wanted to point out that marriage and family therapists are licensed providers of a clinical service in this state. They are mental health providers and however you describe that, it is more or less medical. Marriage and family therapy is regularly mandated to clients in the state via the judicial system and the Division of Family and Youth Services. They seek to repair relational difficulties within the family system. JUDITH FROST said she took time off from work to testify, because she feels strongly about this issue. She said acupuncture has been much more effective than any other alternative she has tried for her sleep disorder and depression from the death of her daughter. She tried traditional medical treatments and became addicted to valium. She then started going to Suzanne Cortright for acupuncture treatments and found that it was most effective for dealing with her condition. She works for a company that does cover acupuncture. She feels strongly that everyone should be able to have their insurance coverage pay for acupuncture treatment. SENATOR DUNCAN asked what insurance company she used. She replied it was Northwestern. SENATOR KELLY said the committee would take into consideration the testimony heard and bring the bill up at a later date.